5.3.8 Digestive System Disorder - Table 8

Table 8.1. and Irritable Bowel Syndrome Claims

Purpose

The following aims to provide policy guidance on how Irritable Bowel Syndrome (IBS) can be assessed under the Permanent Impairment Guide (PI Guide) as prescribed by the Safety, Rehabilitation and Compensation Act 1988 (SRCA).

Overview

Irritable Bowel Syndrome is characterised by chronic, usually intermittent, abdominal pain and altered bowel habit. It is not associated with malnutrition, weight loss, rectal bleeding, or pain that interferes with sleep. It most usually requires diagnosis by a Gastroenterologist after exclusion of other pathologies. Most patients experience mild symptoms though, in rare severe cases, it can cause significant disability and interference with life.

While objective evidence of IBS can exist, it is possible, and indeed common, for the condition to be diagnosed without any objective evidence of disease. However, the PI Guide requires objective signs or symptoms of disease be present before any whole person impairment (WPI) rating can be given.

While impairment ratings are possible for clients with an IBS diagnosis, the most common impairment rating for most IBS cases will still be 0 points, as the symptomology of prototypical IBS cases will not be enough to rate on the PI Guide tables– only relatively severe cases will attract a rating under table 8.1.

Objective signs refers to evidence of the condition which is perceptible to the examiner. Subjective sensations of the individual is not acceptable. This concept is reinforced in several cases before the Administrative Appeals Tribunal (AAT).

In the case of ReFlorit and Comcare (2004) 81 ALD 774, the AAT considered the meaning of ‘objective signs’:

The need for ‘objective signs’ means, in our view, the need for objective signs of a stomach disorder to be present on an ongoing basis such as, for example, by way of endoscopy. In a medical context the adjective ‘objective’ is used to refer to a sign or symptom that can be perceived by others in addition to the patient. A symptom only the patient can perceive is ‘subjective’.

It is possible for there to be objective signs of IBS.

In order of likelihood of being mentioned, some objective signs are:

Sign

Commentary

Variable abdominal distention

This may be noted on clinical examination (on at least 2 occasions) and represent bloating and/or constipation. Abdominal distention on one occasion, or unchanging, is not a useful finding.

Variable abdominal tenderness

This is a weak sign, but may provide the Specialist with additional diagnostic evidence if the condition is being considered. There would be scope for the Delegate to use this as evidence, if it was felt that a rating was justified.

A stool diary

The recording of stool frequency and consistency is performed in a standardised manner in healthcare settings.

Variation, in the setting of a consistent diet, would be strong supporting evidence of IBS.

Any abnormal frequency, even if regular, is objective only if kept by a third party (e.g. by a nurse).

Recording of pain (part of standard “observations” in the hospital setting) and comparison to the timing of defecation might demonstrate a relationship and would thus be objective.

Patients are often asked to keep a stool diary for a period of time to assess response to treatment. This could be considered objective, at the discretion of the Specialist and/or the Delegate.

Intestinal / colonic transit time

This could be represented by either increased or decreased transit time. This is unlikely to be specifically tested in IBS, but may be noted as part of the work-up to exclude other conditions. This may be seen on a CT scan with oral contrast, or a “pill-cam” test.

This list is not exhaustive; other tests or signs may be appropriate as the medical science consensus around IBS improves or changes. Delegates should consult with Policy if unsure whether a claimed sign or symptom is objective.

Some of the tests for objective signs can be invasive and may not be possible in all cases. Again, the suggestions above are not prescriptive - in situations where an assessing medical practitioner is satisfied that a patient is able to show objective signs, then it is open for the delegate to accept the evidence and assessment provided.

Table 8.1 also requires the finding of weight loss at certain impairment levels. Generally, weight loss is not a recognised component of IBS. Therefore, this limits the possible ratings under PIG for IBS to the following:

All other ratings are not possible, as they require that weight loss must be present.

The advice provided in this article is general in nature and does not take into account individual circumstances. Delegates must always consider the medical information available to them and make assessments and determinations accordingly.

5.3.8.1 IBS Case Examples

5.3.8.1. - Case Studies

Case 1. A 32-year-old female veteran with symptoms of recurrent abdominal pain and loose stools. She has experienced these symptoms since developing gastroenteritis on deployment to East Timor. Her symptoms are worse during stressful periods, but currently mild. She is currently working full time. Pain is rated at 3/10 at worst, and she has loose stools 2-3 days per week but no incontinence. She takes pain killers only occasionally.

Discussion. This is the typical picture of mild IBS.

Case 2. A 40 year old male veteran diagnosed with IBS as a consequence of PTSD. He describes significant bloating and abdominal pain on most days and suffers mainly from constipation, though with episodes of diarrhoea for a few days once a month. He has been placed on a low FODMAP, high fibre diet by his Gastroenterologist with good effect and takes no regular medication.

Discussion. This is a typical DVA client with IBS. A medically prescribed dietary restriction is required for control.

Case 3. A 25 year old male veteran developed Major Depression and IBS after a motor vehicle rollover during training. His depressive symptoms are in partial remission following extensive psychological therapy. However, he still had 2-3 loose bowel actions each day, each with an urgent need to defecate, which interfered with his work duties. A trial of sertraline was initiated with a reduction in frequency and urgency of defecation.

Discussion. This is a typical DVA client with IBS. Medication specifically prescribed for this condition has provided reasonable control.

In both case 2 and case 3, the level of impairment and the requirement for treatment likely warrant a rating of 10% on the presentation of objective evidence. It can be almost guaranteed that if either veteran was admitted to hospital (e.g. for a colonoscopy), a stool chart maintained by nursing staff would demonstrate significant variation in bowel habit. It would be inappropriate to request this for assessment purposes, but this should not preclude the Delegate from awarding an appropriate rating, should such testing be available and provided.

In other words, the assessment criteria require objective testing showing objective signs of disease. Without this, a rating cannot be awarded. However, due to the nature of the testing, delegates should not push a client to undertake this testing.

Case 4. A 20 year old female recruit, living on base, reports daily 7/10 abdominal pain and constipation since enlistment. She has required 1-2 days off from work each month. After investigation of gynaecological pathology and a colonoscopy revealed no abnormalities, a diagnosis of IBS is made. The recruit commenced a low FODMAP diet and believes this has helped.

Discussion. This is a typical DVA client with IBS. However, the reported symptoms are not consistent with the functional impact and treatment has been self-prescribed.

There are inconsistencies in the clinical picture in case 4. While there is some dietary modification, and moderate symptoms, it is not clear that a rating of 10% is appropriate. In this context, truly objective evidence provided by a veteran’s treating Specialist may be sufficient in increase the rating to 10%, but it should not be assumed that such evidence exists.

Case 5a. A 45 year old female veteran presents with abdominal pain on most days, worse after meals. She had 4-5 episodes of diarrhoea every day, with no mucus. Gastroscopy and colonoscopy, including biopsy of colon, revealed no abnormality. A diagnosis of IBS was made by a Gastroenterologist. In conjunction with a dietitian, an exclusion diet was prescribed. Escitalopram was prescribed. This combination of treatments reduced the frequency of loose stools to once daily, but there was an increase in bloating and the severity of abdominal pain. The veteran preferred to manage the pain rather than frequent bowel actions so no further changes were made and the opinion of the Gastroenterologist was that the condition could not be improved further.

Discussion. This is a moderately severe case of IBS which has partially responded to treatment.

Case 5b. The veteran subsequently reports that she partook a trial of a new treatment for IBS. As part of the trial, she underwent formal testing of her gastro-intestinal transit time, the gut microbiota, and intestinal neurological testing. The findings are consistent with IBS and markedly different to normal function.

Discussion. This is a moderately severe case of IBS which has partially responded to treatment.